Clinical Guidelines for the Clinical Guidelines for the Management of Hyperglycemia Management of Hyperglycemia in Hospitalized Patients in a in Hospitalized Patients in a Non-Critical Care SettingNon-Critical Care Setting Work in Work in ProgressProgress
The Endocrine Society, The Endocrine Society, European Endo Society, European Endo Society, American Heart Association, American Heart Association, American Diabetes Association, American Diabetes Association, Society of Hospitalist Medicine, Society of Hospitalist Medicine, American Association of Diabetes American Association of Diabetes Educators Educators
Inpatient Hyperglycemia in non-Inpatient Hyperglycemia in non-critical care settingcritical care setting
1.1. What is the frequency of hyperglycemia What is the frequency of hyperglycemia and diabetes? and diabetes?
2.2. What diagnosis criteria should we use?What diagnosis criteria should we use?
3.3. What is the association between What is the association between hyperglycemia and outcomes?hyperglycemia and outcomes?
4.4. How should we manage hyperglycemia in How should we manage hyperglycemia in non-ICU setting?non-ICU setting?
Hyperglycemia: Scope of the ProblemHyperglycemia: Scope of the Problem
Kosiborod M, et al. J Am Coll Cardiol. 2007;49(9):1018-183:283A-284A.
No Diabetes
26%
Diabetes 50
40
30
20
10
0<110110-140
50
40
30
20
10
0<110110-140 140-170170-200>200
78%
140-170170-200>200
Mean BG, mg/dL
Pati
en
ts,
%
Hyperglycemia*: A Common Hyperglycemia*: A Common Comorbidity in Medical-Surgical Comorbidity in Medical-Surgical Patients in a Community HospitalPatients in a Community Hospital
62%62%
12%12%
26%26%
NormoglycemiaNormoglycemia
Known DiabetesKnown Diabetes
New HyperglycemiaNew Hyperglycemia
Umpierrez G et al, J Clin Endocrinol Metabol 87:978, 2002Umpierrez G et al, J Clin Endocrinol Metabol 87:978, 2002
n = 2,020n = 2,020
* Hyperglycemia: Fasting BG * Hyperglycemia: Fasting BG 126 mg/dl 126 mg/dl or Random BG or Random BG 200 mg/dl X 2 200 mg/dl X 2
New and Stress hyperglycemiaNew and Stress hyperglycemia
Patients with hyperglycemia without a previous history of diabetes should be tested with a hemoglobin A1C during the hospital stay or with an oral glucose tolerance test after discharge to confirm the diagnosis of diabetes.
Less than 35% of patients had normal glucose tolerance after 3 to 12 months of follow-up.
Norhammar et al. Lancet 2002; 359(9324): 2140-4.Arora et al. Endocr Pract 2009; 15(5): 425-30.Greci et al. Diabetes Care 2003; 26(4): 1064-8.
IGT and Undiagnosed T2DM are IGT and Undiagnosed T2DM are Common in Acute MI and StrokeCommon in Acute MI and Stroke
Norhammar A, et al. Lancet 2002;359:2140−4.Matz K, et al. Diabetes Care 2006;792−7.
2-hour OGTT
70
60
50
40
30
20
10
0
Norhammar(n=181)
Matz(n=238)
Pati
ents
(%
)
66
39
Myocardial infarction
Stroke
IGT Undiagnosed T2DM
3523
31
16
Epidemiology of Inpatient Epidemiology of Inpatient Hyperglycemia in non-critical care Hyperglycemia in non-critical care settingsetting1.1. What is the frequency of hyperglycemia What is the frequency of hyperglycemia
and diabetes? and diabetes?
2.2. What diagnosis criteria should we use?What diagnosis criteria should we use?
3.3. What is the association between What is the association between hyperglycemia and outcomes?hyperglycemia and outcomes?
4.4. How should we manage hyperglycemia in How should we manage hyperglycemia in non-ICU setting?non-ICU setting?
NORMAL IFG or IGT PREDIABETES
DIABETES
FPG < 100 mg/dl FPG > 100 - 125 mg/dl (IFG)
FPG > 126 mg/dl
2-h PG < 140 mg/dl
2-h PG > 140 - 199 mg/dl (IGT)
2-h PG > 200 mgRandom PG > 200 + symptoms
A1C 5.7% to 6.4% ≥ 6.5%
ADA 2010 - Categories of Increased Risk for Diabetes*
ADA Clinical Practice Recommendations, January 2019
A1C for Diagnosis of Diabetes in A1C for Diagnosis of Diabetes in the Hospitalthe Hospital
Inhospital hyperglycemia is defined as an Inhospital hyperglycemia is defined as an admission or inhospital BG > greater 140 admission or inhospital BG > greater 140 mg/dl. mg/dl.
HbA1c > 6.5% can be identified as having HbA1c > 6.5% can be identified as having diabetes, and patients with A1C 5.7%-6.4% diabetes, and patients with A1C 5.7%-6.4% can be considered as being at risk for can be considered as being at risk for diabetes. diabetes.
Implementation of A1C testing can be Implementation of A1C testing can be useful:useful: assess glycemic control prior to admissionassess glycemic control prior to admission assist with differentiation of newly diagnosed assist with differentiation of newly diagnosed
diabetes from stress hyperglycemiadiabetes from stress hyperglycemia designing an optimal regimen at the time of designing an optimal regimen at the time of
dischargedischarge
Comparison of sensitivity and specificity achieved for the diagnosis of diabetes based on FPG, at various levels of HbA1c, from NHANES III and 1999–2004 NHANES
J Clin Endocrinol Metab, July 2008, 93(7):2447–2453
Factors influencing A1cFactors influencing A1c
Epidemiology of Inpatient Epidemiology of Inpatient Hyperglycemia in non-critical care Hyperglycemia in non-critical care settingsetting1.1. What is the frequency of hyperglycemia What is the frequency of hyperglycemia
and diabetes? and diabetes?
2.2. What diagnosis criteria should we use?What diagnosis criteria should we use?
3.3. What is the association between What is the association between hyperglycemia and outcomes?hyperglycemia and outcomes?
4.4. How should we manage hyperglycemia in How should we manage hyperglycemia in non-ICU setting?non-ICU setting?
Hyperglycemia and Pneumonia Hyperglycemia and Pneumonia OutcomesOutcomes
0
5
1 0
1 5
2 0
2 5
3 0
M o r ta l it y
H o s p ita lC o m p lic a t io n s
BG (mg/dl) < 110 110 - <198 198 - <250 ≥250
* *
* *
* p: < 0.05 vs BG < 198 mg/dl (11 mmol/L)
Admission glucose (mg/dl)
%
McAllister et al, Diabetes Crae 28:810-815, 2005McAllister et al, Diabetes Crae 28:810-815, 2005
N= 2,471 patients with CAP
Community Acquired Pneumonia Community Acquired Pneumonia Outcomes in Patients with DiabetesOutcomes in Patients with Diabetes
0
20
40
60
80
100
%
Hospitalization Mortality Pleural Effusion Concomitant IllnessesP: < 0.001
N= 660 (DM: 106 & non-DM: 554)No differences in microorganisms and bacteremia rates
Falguera et al, Chest 128:3233-3239, 2005Falguera et al, Chest 128:3233-3239, 2005
*
*
*
*
93
817
78
31
18
53
40*
Diabetes
No Diabetes
A case control study of 108,593 patients who underwent noncardiac surgery.
*Odds ratio for perioperative mortality is 1.19 (95% CI 1.1–1.3) per mmol/l increase of glucose level
Thirty Day Mortality and Inhospital Complications in diabetic and non-diabetic subjects
†p = 0.1 * p= 0.001 #p=0.017
†
*
**
*#
*
%
A Frisch et al. Diabetes Care, May 2010
Hyperglycemia and mortalityHyperglycemia and mortality
Mean POSTSURGERY blood glucose and ODDS RATIOS for 30 day mortality in diabetic and non diabetic patients
0
10
20
30
40
50
60
50 100 150 200 250 300Odds
ratio
for 3
0-d
ay m
orta
lity
Mean blood glucose after surgery (mg/dl)
All patients Diabetics non-Diabetics
A Frisch et al. Diabetes 58 (suppl 1) A27, 2009
Hyperglycemia: An Independent Marker of In-Hospital Mortality in Patients with Undiagnosed Diabetes
Total In-patient MortalityTotal In-patient Mortality
NormoglycemiaNormoglycemia Known Known New New DiabetesDiabetes Hyperglycemia Hyperglycemia
1.7%1.7% 3.0%3.0%
16.0% 16.0% **
Mort
alit
y (
%)
Mort
alit
y (
%)
* P < 0.01* P < 0.01
Umpierrez GE et al, J Clin Endocrinol Metabol 87:978, 2002Umpierrez GE et al, J Clin Endocrinol Metabol 87:978, 2002
AACE/ADA Target Glucose Levels AACE/ADA Target Glucose Levels in Nonin Non––ICU PatientsICU Patients
Glucose Target in nonGlucose Target in non––ICU setting:ICU setting: Premeal glucose targets <140 mg/dL Premeal glucose targets <140 mg/dL Random BG <180 mg/dLRandom BG <180 mg/dL To avoid hypoglycemia, reassess insulin To avoid hypoglycemia, reassess insulin
regimen if BG levels fall below 100 mg/dLregimen if BG levels fall below 100 mg/dL Occasional patients may be maintained with a Occasional patients may be maintained with a
glucose range below and/or above these cut-glucose range below and/or above these cut-points points
Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009;15(4). http://www.aace.com/pub/pdf/guidelines/InpatientGlycemicControlConsensusStatement.pdf
Epidemiology of Inpatient Epidemiology of Inpatient Hyperglycemia in non-critical care Hyperglycemia in non-critical care settingsetting1.1. What is the frequency of hyperglycemia What is the frequency of hyperglycemia
and diabetes? and diabetes?
2.2. What diagnosis criteria should we use?What diagnosis criteria should we use?
3.3. What is the association between What is the association between hyperglycemia and outcomes?hyperglycemia and outcomes?
4.4. How should we manage hyperglycemia in How should we manage hyperglycemia in non-ICU setting?non-ICU setting?
1.ACE/ADA Task Force on Inpatient Diabetes. Diabetes Care. 2006 & 20092.Diabetes Care. 2009;31(suppl 1):S1-S110..
Antihyperglycemic Therapy
Insulin Recommended
OADs Not Generally
Recommended
IV Insulin
Critically ill patients in the ICU
SC Insulin
Non-critically ill patients
Recommendations for Managing Patients With Diabetes in the Hospital Setting
AACE/ADA Consensus StatementAACE/ADA Consensus Statement Non-insulin therapies in the Non-insulin therapies in the hospital?hospital?Sulfonylureas are a major cause of Sulfonylureas are a major cause of
hypoglycemiahypoglycemiaMetformin contraindicated in setting of decrease Metformin contraindicated in setting of decrease
renal blood flow and with use of iodinated renal blood flow and with use of iodinated contrast dyecontrast dye
Thiazolidinediones associated with edema and Thiazolidinediones associated with edema and CHFCHF
αα glucosidase inhibitors are weak glucose glucosidase inhibitors are weak glucose lowering agentslowering agents
Pramlintide and GLP1-directed therapies can Pramlintide and GLP1-directed therapies can cause nausea and have a greater effect on cause nausea and have a greater effect on postprandial glucose postprandial glucose
Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009
Management of Hyperglycemia Management of Hyperglycemia and Diabetes in non-ICU Settingand Diabetes in non-ICU Setting
Non-ICUNon-ICU
Sliding Scale Short-Acting Insulin Sliding Scale Short-Acting Insulin
Basal/bolus therapy (MDI)Basal/bolus therapy (MDI)• NPH and Regular insulinNPH and Regular insulin• Long-acting and rapid-acting insulinLong-acting and rapid-acting insulin
Premix insulinPremix insulin
Study Type: Prospective, multicenter, randomized, open-label trial
Patient Population: 130 subjects with DM2 Diet and/or oral hypoglycemic agents
Umpierrez et al, Diabetes Care 30:2181–2186, 2007
D/C oral antidiabetic drugs on admissionD/C oral antidiabetic drugs on admission
Starting total daily dose (TDD): Starting total daily dose (TDD): 0.4 U/kg/d x BG between 140-200 mg/dL0.4 U/kg/d x BG between 140-200 mg/dL 0.5 U/kg/d x BG between 201-400 mg/dL 0.5 U/kg/d x BG between 201-400 mg/dL
Half of TDD as insulin glargine and half as Half of TDD as insulin glargine and half as rapid-acting insulin (lispro, aspart, rapid-acting insulin (lispro, aspart, glulisine)glulisine) Insulin glargine - once daily, at the same Insulin glargine - once daily, at the same
time/day. time/day. Rapid-acting insulin- three equally divided Rapid-acting insulin- three equally divided
doses (AC)doses (AC)
RaRandomized ndomized BBasal asal BBolus versus Sliding Scale olus versus Sliding Scale Regular Regular IInsulin in patients with nsulin in patients with ttype ype 22 Diabetes Diabetes
MellitusMellitus(RABBIT-2 Trial)(RABBIT-2 Trial)
Umpierrez et al, Diabetes Care 30:2181–2186, 2007
Umpierrez GE et al. Diabetes Care. 2007;30:2181-2186.
• Before meal: Supplemental Sliding Scale Insulin (number of units)
– Add to scheduled insulin dose
• Bedtime: Give half of Supplemental Sliding Scale InsulinBlood Glucose
(mg/dL) Insulin Sensitive Usual Insulin Resistant
>141-180 2 4 6
181-220 4 6 8
221-260 6 8 10
261-300 8 10 12
301-350 10 12 14
351-400 12 14 16
>400 14 16 18
Sliding Scale Insulin Regimen
Rabbit 2 Trial: Changes in Glucose Levels Rabbit 2 Trial: Changes in Glucose Levels With Basal-Bolus vs. Sliding Scale InsulinWith Basal-Bolus vs. Sliding Scale Insulin
Umpierrez GE, et al. Diabetes Care. 2007;30(9):2181-2186.
Days of Therapy
BG
, m
g/d
L
100
120
140
160
180
200
220
240
Admit 1
Sliding-scale
Basal-bolus
bP<.05.
aa a
b bb
b
2 3 4 5 6 7 8 9 10
aP<.05.
• Sliding scale regular insulin (SSRI) was given 4 times daily • Basal-bolus regimen: glargine was given once daily; glulisine was given before meals.0.4 U/kg/d x BG between 140-200 mg/dL0.5 U/kg/d x BG between 201-400 mg/dL
Persistent hyperglycemia (BG>240 Persistent hyperglycemia (BG>240 mg/dl) is common (15%) during SSI mg/dl) is common (15%) during SSI therapytherapy
Days of Therapy
BG
, m
g/d
L
100120140160180200220240
Admit1
Sliding-scale
Basal-bolus
260280300
3 3 4 5 6 72 4 21
Rabbit 2 Trial: Treatment Success With Basal-Bolus vs. Sliding Scale
Insulin
Hypoglycemia Hypoglycemia rate:rate:
Basal Bolus Group: BG < 60 mg/dL: 3% BG < 40 mg/dL:
none
SSRI: BG < 60 mg/dL: 3% BG < 40 mg/dL: none
Umpierrez GE, et al. Diabetes Care. 2007;30(9):2181-2186.
Study Type: Prospective, randomized, open-label trial
Patient Population: 130 subjects with DM2 Oral hypoglycemic agents or insulin therapy
Study Sites: Grady Memorial Hospital, Atlanta, GARush University Medical Center, Chicago, IL
Umpierrez et al, J Clin Endocrinol Metab 94: 564–569, 2009
Detemir–Aspart Insulin Regimen
• D/C oral antidiabetic drugs on admission
• Starting total daily dose (TDD): – 0.4 U/kg/d x BG between 140-200 mg/dL– 0.5 U/kg/d x BG between 201-400 mg/dL
• Half of TDD as insulin detemir and half as aspart– Insulin detemir - once daily, at the same time
of the day. – Insulin aspart - three equally divided doses
(AC)
Umpierrez et al, J Clin Endocrinol Metab 94: 564–569, 2009
NPH–Regular Split-Mixed Regimen
• D/C oral antidiabetic drugs on admission
• Starting total daily dose (TDD): – 0.4 U/kg/d x BG between 140-200 mg/dL– 0.5 U/kg/d x BG between 201-400 mg/dL
• Three-fifth of TDD as insulin NPH and two-fifth as regular– NPH insulin– twice daily, 2/3 before breakfast,
1/3 before dinner – Regular insulin- twice daily, 2/3 before
breakfast, 1/3 before dinner
Umpierrez et al, J Clin Endocrinol Metab 94: 564–569, 2009
DEAN Trial: Changes in Mean Daily DEAN Trial: Changes in Mean Daily Blood Glucose ConcentrationBlood Glucose Concentration
BG
, m
g/d
L
Duration of Therapy, d
Data are means SEM.
Detemir + aspartNPH + regular
Basal-bolus regimen: detemir was given once daily; aspart was given before meals.NPH/regular regimen: NPH and regular insulin were given twice daily, two thirds in AM, one third in PM.Umpierrez GE, et al. J Clin Endocrinol Metab. 2009;94(2):564-569.
P=NS
100
120
140
160
180
200
220
240
Pre-RxBG
0 1 2 3 4 5 6-10
120
140
160
180
200
Breakfast Lunch Dinner Bedtime
Blo
od
glu
cose
(m
g/d
L)
Detemir + NovologNPH + Regular
DEAN-Trial
NPH/Regular BG < 40 mg/dl: 1.6% BG < 60 mg/dl: 25.4%
Detemir/Aspart BG < 40 mg/dl: 4.5% BG < 40 mg/dl: 32.8%
Umpierrez et al, J Clin Endocrinol Metab 94: 564–569, 2009
DEAN Trial: Hypoglycemia
To determine risk factors for
hypoglycemic events during SC insulin therapy
p-value*
variable BG < 60 mg/dl BG < 70 mg/dl
AGE 0.036 0.001
wt 0.027 0.001
A1C 0.521 0.658
Creatinine 0.011 0.002
Enrollment BG 0.166 0.319
Previous treatment 0.005 <.001Previous insulin Rx <0.001 <.001
Treatment group <0.001 <.001*p-values are from Wilcoxon Two-Sample Test
Summary of Univariate Analyses
Umpierrez et al, ADA Scientific Meeting, Poster #516, 2009
RAndomized Study of Basal Bolus RAndomized Study of Basal Bolus Insulin Therapy in the Inpatient Insulin Therapy in the Inpatient Management of Patients with Type 2 Management of Patients with Type 2 Diabetes Undergoing General Diabetes Undergoing General Surgery: RABBIT Surgery TrialSurgery: RABBIT Surgery Trial
Guillermo E Umpierrez, Dawn Smiley, Sol Guillermo E Umpierrez, Dawn Smiley, Sol Jacobs, Limin Peng, Angel Temponi, Jacobs, Limin Peng, Angel Temponi, Christopher Newton, Denise Umpierrez, Christopher Newton, Denise Umpierrez, Patrick Mulligan, Darin Olson, Jana MacLeod, Patrick Mulligan, Darin Olson, Jana MacLeod, Monica Rizzo. Monica Rizzo.
Umpierrez et al, Preliminary data- ADA Scientific Session 2010
Research Design and MethodsResearch Design and Methods
Study Type: Multi-center, prospective, open-label randomized clinical trial
Patient Population: Patients with type 2 DM admitted to general surgery services
Study Sites: Grady Memorial Hospital, Veterans Affairs Medical Center and Emory University Hospital, Atlanta, GA
Treatment Groups: Group 1: basal/bolus regimen with glargine once
daily and glulisine before meals Group 2: sliding scale regular insulin (SSRI) four
times daily
Umpierrez et al, Preliminary data- Abstract submitted to ADA Scientific Session 2010
Primary outcome: • Differences between groups in mean daily BG
concentration
• Composite of hospital complications including: postoperative wound infection, pneumonia, respiratory failure, acute renal failure, and bacteremia.
Secondary outcome:
Differences between groups in any of the following measures:
•Mean fasting and pre-meal BG, number of hypoglycemic (BG < 70 mg/dL and < 40 mg/dL) and hyperglycemic (BG > 200 mg/dL) events , length of hospital stay, need for ICU care, and rate of complications including wound infection, pneumonia, acute renal failure, and mortality.
211 Patients with type 2 DM that underwent general surgery
Glargine + Glulisine(Gla+Glu)N= 104
Group 1: 0.5 U/kg
Half as glargine once daily Half as glulisine before meals
Sliding scale insulin (SSRI) N= 107
OPEN-LABELED RANDOMIZATION
Group 2: 4 times/day for BG >140 mg/dl
RABBIT SURGERY TRIAL
RABBIT 2 SURGERY
Umpierrez et al, Preliminary data- Abstract to be submitted_ADA Scientific Session 2010
120
140
160
180
200
220
0 1 2 3 4 5 6 7 8 9 10 11
Bloo
d Gl
ucos
e (m
g/dL
)
*† ‡
*
Duration of Treatment (days)
1 2 3 4 5 6 7 8 9 10
† †
Randomi-zation
Rabbit Surgery TrialGlucose levels during Basal Bolus and SSRI
Therapy
* p<0.001 † p: 0.01ŧ p: 0.02
SSIGLA+GLU
Glucose levels Before meals and Bedtime
120
140
160
180
200
220
-0.25 0.75 1.75 2.75
Bloo
d G
luco
se (
mg/
dL)
*
*
Duration of Treatment (days)
Breakfast Lunch Dinner Bedtime
* *SSI
Basal Bolus
Differences in BG Concentration Within TargetDuring Hospital Stay and After 24 Hours of Treatment
Hospital Complications: Primary outcome
Umpierrez et al, Preliminary data- Abstract to be submitted_ADA Scientific Session 2010
Hypoglycemic Events
Treatment with glargine once daily plus glulisine before meals improved glycemic control and reduced hospital complications compared to SSRI in general surgery patients with T2DM.
Our study indicates that basal/bolus insulin regimen is the preferred insulin regimen in the hospital management of general surgery patients with type 2 diabetes.
Summary & Conclusion Summary & Conclusion RABBIT 2 SURGERY
Management RecommendationsManagement Recommendations
All patients with T1DM must receive insulin All patients with T1DM must receive insulin treatment with basal bolus, multi-dose insulin treatment with basal bolus, multi-dose insulin combination of NPH plus regular insulin or combination of NPH plus regular insulin or continuous insulin pump.continuous insulin pump.
Patients treated with insulin at home should be Patients treated with insulin at home should be continued with insulin therapy in the hospital.continued with insulin therapy in the hospital.
Scheduled subcutaneous basal bolus insulin regimen Scheduled subcutaneous basal bolus insulin regimen is preferred for the majority of non-critically ill is preferred for the majority of non-critically ill patients with hyperglycemia. patients with hyperglycemia.
The practice of using sliding scale insulin (SSI) as a The practice of using sliding scale insulin (SSI) as a single form of therapy is undesirable.single form of therapy is undesirable.
Strategies for Preventing Strategies for Preventing HypoglycemiaHypoglycemia
In-service training on new treatment In-service training on new treatment modalities and the actions of new modalities and the actions of new antihyperglycemic agentsantihyperglycemic agents
Braithwaite SS, et al. Endocr Pract. 2004;10(suppl 2):89-99.
Reducing outpatient insulin dose in patients treated with insulin prior to admission
Basal Bolus is preferred over SSRI and NPH/regular combination
D/C oral antidiabetic drugs on admissionD/C oral antidiabetic drugs on admission
Starting total daily dose (TDD): Starting total daily dose (TDD): 0.3 U/kg/d in elderly and renal failure (lean?)0.3 U/kg/d in elderly and renal failure (lean?) 0.4 U/kg/d x BG between 140-200 mg/dL0.4 U/kg/d x BG between 140-200 mg/dL 0.5 U/kg/d x BG between 201-400 mg/dL 0.5 U/kg/d x BG between 201-400 mg/dL
Half of TDD as insulin glargine and half as Half of TDD as insulin glargine and half as rapid-acting insulin (lispro, aspart, rapid-acting insulin (lispro, aspart, glulisine)glulisine)
Decrease outpatient insulin dose by 20-Decrease outpatient insulin dose by 20-25% 25%
Basal Bolus Insulin Regimen in T2DM: SummaryBasal Bolus Insulin Regimen in T2DM: Summary
Umpierrez et al, Diabetes Care 2007; JCEM 2009; Diabetes 2010
120
140
160
180
200
220
0 1 2 3 4 5 6 7 8 9 10 11
Bloo
d Gl
ucos
e (m
g/dL
)
*† ‡
*
Duration of Treatment (days)
1 2 3 4 5 6 7 8 9 10
† †
Randomi-zation
Rabbit Surgery TrialGlucose levels during Basal Bolus and SSRI
Therapy
* p<0.001 † p: 0.01ŧ p: 0.02
Mainly Basal (Glargine) Insulin
4:004:00 16:0016:00 20:00 20:00 24:0024:00 4:004:00 8:008:0012:0012:008:008:00TimeTime
Glargine once daily
0.25 U/kg
Basal-PLUS Insulin RegimenBasal-PLUS Insulin RegimenIn
su
lin
Acti
on
Leahy J. In: Leahy J, Cefalu W, eds. Insulin Therapy. New York: Marcel Dekker; 2002:87; Nathan DM. N Engl J Med. 2002;347:1342
Aspart, Lispro or Apidra before meals per sliding scale
A1C < 7%
Re-start outpatient treatment regimen
(OAD and/or insulin)
A1C 7%-9%
Re-start outpatient oral agents and D/C
on glargine once daily at
50-80% of hospital dose
A1C >9%
D/C on basal bolus at same hospital
dose.
Alternative: re-start oral agents
and D/C on glargine once daily
at 50-80% of hospital dose
Discharge insulin Algorithm
Discharge Treatment
Needed Research StudiesNeeded Research Studies
What is the role of medical nutrition therapy in What is the role of medical nutrition therapy in non-critical care setting? non-critical care setting?
How should glycemia be monitored in non-How should glycemia be monitored in non-critical care setting? critical care setting?
How should hyperglycemia be managed across How should hyperglycemia be managed across transitions in care? transitions in care?
What are the best predictors of hypoglycemia?What are the best predictors of hypoglycemia? What is the financial impact of glycemic What is the financial impact of glycemic
control in non-critical care areas? control in non-critical care areas?
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